Treatment of First Unprovoked (Nonfebrile) Seizure

Definitions

Epilepsy: Disorder of the brain characterized by an enduring predisposition to generate seizures and by the neurobiological, cognitive, psychological, and social consequences of this condition. (1)

Unprovoked Seizure: Seizure as a transient occurrence of signs and or symptoms as a result of abnormal excessive or enhanced synchronous neuronal activity in the brain that cannot be associated with a precipitating factor. (1)

Seizures that were excluded were one’s associated with epilepsy which could not be diagnosed after one seizure, neonatal seizures, and seizures that were caused by an obvious cause such as CNS trauma, CNS insult, or infection

Epidemiology

Incidence of seizures:

10% of the population will have had at least one seizure in their lifetime.

25,000-40,000 children in the US will experience an unprovoked seizure a year

Risk of recurrence:

Current research is highly variable and is dependent on age of occurrence

The younger the appearance of the first seizure, the higher the risk

All studies performed have level 3 evidence and range from 15%-46%

Recurrence of multiple seizures are also highly variable

Incidence is higher in children with prior insult such as Cerebral Palsy or Mental Retardation

Incidence also higher with patients who had abnormal EEG pattern

Management

Common Drugs and Side Effects

There is level 2 evidence that use of AED’s have serious side effects including serious cognitive, behavioral, and system side effects. The worst of these is phenobarbital where rates of systemic side-effects range anywhere from 4%-58%!!!!!

Only one RCT shows reduced risk after 1-yr follow up of recurrence after treatment with Carbamazepine (14% vs. 53%).

One RCT tested Valproic Acid in both adults and pediatric patients, showing 4% risk of recurrence vs. 46%. However, another study with similar design showed no difference.

Is treatment after first seizure effective for long-term prognosis?

Currently 2 level 2 studies show that there is no long term benefit of starting treatment after first seizure vs. after second seizure in achieving a 1-2 year remission of seizure activity

Conclusion

Overall there is some weak evidence that treatment with AED after a first unprovoked seizure reduces seizure activity short term. There is stronger evidence that treatment after first seizure does not improve long term prognosis and remission rates of seizure activity compared to treatment after 2nd unprovoked seizure.

Current recommendations:

First unprovoked seizure should NOT be routinely treated with AED; instead, risks of recurrent seizures and their sequelae should be weighed against possible side effects of chronic AED use.

AED use does NOT prevent epilepsy, as shown by no difference in long-term outcomes in treatment and no treatment groups.